The belief that people with psychological problems can change - can learn more adaptive ways of perceiving, evaluation, and behaving - is the conviction underlying all psychotherapy.
People's worldview and self-concept are set and reinforced by our experiences and environment.
- Because change can be hard, people often go on without help with these difficulties. Therapy takes time as well.
However, psychotherapy does show promise even for the most severe mental disorders.
People seek Therapy because of:
1) stressful life events such as divorce or unemployment, 2) because of long-standing problems and maladjustment behaviours of chronic unhappiness and despair. Although these patients may have a strong motive when starting, when their maladaptive behaviour is challenged, they can push back. It is the counselor to help build a strong relationship to work through this.
3) indirect referral due to patients seeking other resources for answers to their health questions ( such as a physician referral), or due to the suggestion of a friend or family member. Males tend to be more reluctant than women to enter therapy.
4)Their desire to see their personal growth. These are relatively normal individuals but enter because they feel they have no lived up to their potential.
Psychotherapy is not just for people with clearly defined problems. It also benefits even severely disturbed patients that take into account their level of functioning and maintains therapeutic subgoals within their capabilities. There is no typical client or model therapy. There is no one type of therapy that applies to al situations. Clients variables such as motivation to change and severity of symptoms all [lay a role in the outcome of therapy. Some therapies have greater success rates than others, especially when the therapist takes the characteristics of the patient into account when determining treatment approaches.
Therapeutic providers include: Physicians ( who deal with physical but often come to deal with the emotional issues of patients as well), and the clergy ( yet most are limited in their counseling to religious matters and do not provide psychotherapy support).
* Mental health professionals that render psychological treatment include clinical psychologists, psychiatrists ( who can render medications and other medical based treatment), and psychiatric social workers.
* In some states supervised psychologists may administer drugs.
- Psychiatrists often treat mental disorders with biological approaches such as medication, and psychologists and social workers use an examination of behaviour and work to change behaviour and thought patterns.
- A clinic or hospital allows for a wider range of treatments. These range from medications, individual or group therapies, to home, school, or job visits aimed to modify adverse conditions in the client's life.
The willingness to use a variety of approaches in important Ideally to coordinate the efforts of medical, psychological and social workers together to meet the needs they warrant.
- another key approach involves providing community treatment facilities to integrate family and community resources in a total treatment approach opposed to the isolation of home or hospital alone.
* The therapeutic relationship evolves of what both client and therapists bring to the therapeutic situation. The outcomes of psychotherapy normally depend on whether the client and the therapist are successful in producing a strong working alliance. The client's major contributions are his or her motivation. Pessimistic or ambivalent clients respond less well to treatment. The establishment of a strong working alliance is seen at an essential component. The relationship is therapeutic in its right.
A strong therapeutic alliance includes:
1) a sense of working collaboratively on the problem, 2) agreement between patient and therapist about the goal and tasks of therapy, and 3) an effective bond between therapist and patient is established.
Almost as important as motivation is the clients expectation in receiving help. The expectancy in itself is often enough to bring some substantial improvement perhaps because their expectation causes them to engage more in the process.
- If a patient also expects the therapy will not help, there can also be difficulties in its effectiveness due to their inability to engage in the treatment in the same way as if they were motivated.
Qualities that enhance therapy is openness and unconditional positive regard.
- Therapists help bring new perspectives and a safe setting in which the clients are encouraged to practice new ways fo feeling and acting, gradually developing the courage and ability to take responsibility for acting in more effective ways.
- The psychotherapist must be successful in helping the client give up their old ways and patterns and replacing them with new functional ones. The therapist must be flexible to the varying challenges presented in the process.
- attempts at estimating client gains in therapy generally depend on the following 1) therapists impression of the changes that have occurred, 2) a client's report of the changes, 3) reports from the clients friends or family, 4) comparison of pretreatment and posttreatment scores of personality tests or other instruments intended to measure relevant facets of psychological functioning and 5) measures of change in select overt behaviours.
- a therapist may not be the best judge of success as they will be biased in outcomes that better represent their skills.
- a therapist only has a limited overall observational sample to make the judgement of changes overall, also treating a difficulty.
- Therapists can inflate improvements by subtly encouraging difficult clients to discontinue therapy. The problem with how to deal with early drop outs also further complicated measuring outcomes. Shoudl they be excluded entirely? Or be counted as failures?
A client is also not necessarily a reliable source of information on therapeutic outcomes. Clinets may want to believe that they are getting better more than they are, and in an attempt to please themselves and therapists they report more success than they truly are experiencing. Additionally, because of the financial and time investment that goes into therapy, patients may report more success to avoid having to continue treatment.
to remedy this, clinical ratings by an outside observer are sometimes used in research on psychotherapy outcomes to evaluate the progress of a client; these ratings may be more objective.
Additionally, objective psychological testing can be used to help remedy biased results. These tests are taken before and after therapy and differences in score reflect progress. Unfortunately, some of these tests may produce artificial results, as with regression to the mean, where very high or very low scores tend on repeated measurement to drift towards the average distributions, yielding false impression that some real change has been documented.
Additionally, particular tests may focus on the theoretical predictions of the researcher. Thus they are not necessarily valid predictors of the changes or how the client will behave in real life.
Additional issues that can cause problems in evaluating effectiveness have to do with using generalized terms such as recovery, marked improvement, and moderate improvement, which are often used in outcome research in the past, but are open to considerable differences in interpretation. Emphasis must be placed on more quantitative methods to measure change.
Additionally, in some cases, marked improvement occurs even without professional intervention. Some episodes run a fairly short course with or without treatment
The outcomes of psychotherapy are not always neutral or positive. Some clients are harmed by their encounters with psychotherapists. Those with borderline personality disorder and OCD often have higher rates of negative treatment outcomes.
Problems in the therapeutic alliance account for some of the instances of failure. A mismatch of therapist and client personality characteristics may produce deteriorating outcomes. Certain therapists, possibly for reasons of personality or lack of interpersonal skills, just do to do well with certain types of client problems. In light of these intangible factors, it is ethically required that all therapists
1) monitor their work with various types of clients to discover any such deficiencies, and 2) to refer to other therapists those clients with whom they may be ill-equipped to work.
Unfortunaltey many clinicians are bad at being able to recognize when their clients are not doing well. To address this problem, base research measures to assess clinical deterioration are now being developed. If clinicians are willing to use these in their routine, they will be warned when their client are not progressing in an expected manner. A major hurdle, however, is implementation. The worst therapists are the ones that refuse to use such patient monitoring methods.
A special case of therapeutic harm concerns what are called Boundary Violations when a therapist behaves I a way that is highly inappropriate ( e.g., taking patients out for dinner, or giving them gifts). A sexual relationship between client and therapist is perhaps the most evident and extreme example of severing boundary violation. It is highly unethical. Given the frequency of the interaction between patient and therapist; it is not surprising that feelings can arise. However, it's the responsibility fo the practitioner to maintain appropriate boundaries at all times. When exploitive practices and unprofessional behaviour occurs on the part of the therapist, great harm can come to the patient. Anyone seeking therapy needs to be sufficiently aware enough to determine if the therapist he or she has chosen is committed to high ethical standards.
Additional ways that therapy can be detrimental include if particular therapy used makes symptoms worse make the person more concerned about their symptoms they have or make the client excessively dependent on the therapist to function. Encounters with some therapists or form of therapy also may make a person less willing to seek therapy in the future. All practicing clinicians owe it to their clients to educate themselves about research on potentially harmful treatment. They should also monitor their behaviors and adhere to a high ethical standard of practice. In this way they can minimize the likelihood, they will cause damage to the person who comes to them seeking help.
Efficacy trials - randomised clinical trials on human and other subjects are used to determine if a drug is doing what it is supposed to do. These may become quite elaborate; the basic design is of randomly assigning have the patients with the active drug, and the another half with a placebo. Usually, neither the patient nor the prescriber is aware of the difference; a third part records the information in code. If the group with the active drug show improvement compared to the placebo group in the double-blind procedure, investigators have evidence of its efficacy.
Investigators in psychotherapy outcome have attempted to apply this research design to their field of inquiry with modifications. The main source of frustration has been in creating a placebo the will appear credible to patients. Most such research has thus adopted the strategy of either comparing two or more purportedly active therapies or using no treatment control of the same duration as the active treatment. However, putting a patient on hold can cause some ethical issues by not treating a patient in need.
Another issue is that therapists often differ markedly in the manner in which they deliver therapy. To test a given therapy, it, therefore, becomes necessary to develop a treatment manual to specify just how a treatment under examination should be delivered.
Attempts to manualize therapy has been one way therapists have tried to reduce variability in patients clinical outcomes that much result from characteristics of the therapist themselves. However, this attempt to standardize psychological treatment is often extended by a return to routine clinical practice after efficacy for a particular disorder has been established.
Efficacy studies are becoming increasingly common and typically focus on patients who have a single DSM-IV-TR diagnosis and involve two or more treatment or control conditions, where at least one treatment is a psychological one ( another could be biological). Patricipants are randomly assigned, and effects are evaluated systematically with a common battery of assessment instructions, usually administered both before and after treatment.
Although medications have created a great deal of advancement for patients who would have otherwise been hospitalised for their severe disorders, certain issues have arisen. Many possible unwanted side effects can result. Additionally, there is a struggle in the complexity of matching drug and drug dosage to the needs of a specific client. It is also sometimes necessary for patients to change medications over the course of treatment. Medications used in isolation from other treatments can be unideal for many as well. And still, psychiatric drugs are being administered increasingly at the expense of psychotherapy. This is problematic because drugs alleviate the symptoms by inducing biological changes, not by helping the individual understand and change their personal or situation factors that may be creating or reinforcing the maladaptive behaviours. When drugs are discontinued, patients may be at higher relapse risk.
Overall, the integration of medication and psychotherapy remains common in clinical practice,particularly for disorders such as schizophrenia and bipolar disorder. In some cases patients benefit more from psychotherapy and the psychotherapy can aid in the more effective results of the medications sued. Combined treatments are not always superior to singular treatments. Adding psychiatric medication does not imprve the clinical efficacy of psychosocial treatments for anxiety disorders for example. However, for people suffering from chronic or recurrent depression, combined treatments often result in better clinical outcomes.
Nondirective approach to psychotherapy that focuses on the natural power of the organism to heal itself; a key goal is to help clients accept and be themselves. Developed by Carl Rogers. Therapy is the process of removing the constraints and restrictions that grow out of unrealistic demands that people put on themselves when they believe, as a condition of self-worth, that they should not have certain kinds of feelings. By denying their feelings, they lose their gut reactions. As they lose their genuine experience, the result is lowered integration, impaired social and personal relationships, and various maladjustments.
the primary objective is to resolve this incongruence - to help clients be able to accept themselves.
Client therapists must establish a psychological climate in which clients can feel unconditionally accepted, understood, and values as people. Empathetic reflecting and restatement of clients descriptions allow clients to feel free and explore their true thoughts and feelings. As their self-concept becomes more congruent with their actual experiences, they become more self-accepting and better integrated. Client-centered therapy does not give answers, interpret what the client says, probe the unconscious, or even steer the client towards certain topics. Rather they simply listen devoid of judgment.
Pure client-centered psychotherapy is rarely still practiced today, although it is still popular in Europe. Motivational interviewing is a new form of therapy that is based on this empathetic style.
13th EditionLori Watson, Patrick J. Hurley